Enhancing Patient Education and Access

On this episode of TMU, we’re joined by Nilay Gandhi, Urologist at Potomac Urology in Northern Virginia, as he shares his personal story on why he chose to pursue urology and his involvement in patient advocacy. Dr. Gandhi also discusses how incorporating genetic testing into his practice has improved patient care. Lastly, we’ll cover the growing presence of advanced practice providers in urology and the need for personalized treatment options for prostate cancer patients. Tune in to learn more!

Transcript

0:00:04.3 Myriad Genetics proudly presents the Modern Urologist podcast. This casual yet educational podcast is committed to keeping you informed on all things urology, so you can continue to provide the highest level of care for your patients.

0:00:23.4 Dr. Thomas Slavin: I'm Dr. Thomas Slavin. I am the Chief Medical Officer of Myriad Genetics. Welcome to the Modern Urologist. Today, I am joined by Dr. Gandhi, urologist at Potomac Urology in Northern Virginia. Welcome to the podcast, Dr. Gandhi.

0:00:38.7 Dr. Nilay Gandhi: Well, thank you. Thanks for having me. It's a pleasure to be here. I'm excited. This would be fun.

0:00:43.8 DS: Yeah. Well, first you may tell the audience a little bit about yourself and why you chose urology in the first place.

0:00:51.1 DG: Yeah, so I'm Nilay Gandhi, I'm in Northern Virginia with Potomac Urology, as you mentioned. I trained at Johns Hopkins University, and then I've been down here since 2015. We've got a growing young practice, which is fun and exciting. And private practice has really just allowed me to branch out into things that I didn't ever see myself doing in practice, and that's been the fun of it

0:01:18.6 DS: Yeah, yeah, that's really fun.

0:01:20.7 DG: Yeah, so actually interesting story, my father's a pediatrician like yourself, and I always thought I'd go into pediatrics, but it just wasn't my thing. So after having a couple of knee surgeries, I was convinced I'd go into orthopedics. Again, just not my thing, and I really didn't know what I wanted to go into after going through our rotations, but in medical school, I was actually able to do a pediatric urology rotation. I met a patient who had spina bifida, wheelchair-bound, and was a Special Olympics gold medalist. And he was extremely proud of it. I would talk to him, and he told me how his pediatric urologist changed his life from being incontinent, smelling, and just to having control, being able to catharize, and really just control his functions. That just kind of was really eye-opening to me that a urologist could do that, and I didn't know much about urology, and so as I learned more about it and did rotations on adult urology and learned that you get to play with the lasers and deal with robots, and even you have the potential to cure cancer, with detecting prostate cancer at an early stage, you really can cure people of cancer, which in the world of cancer is somewhat strange to think of. To really say that you can cure cancer I think was just very eye-opening to me, and I haven't looked back ever since, and likely the best decision I've ever made outside of marrying my wife.

0:03:02.5 DS: That's great. And you've always been a big patient advocate, I hear. Tell us a little bit about Pie For Prostate.

0:03:14.7 DG: Yeah, so I think on a previous episode you guys have talked to the company Zero, the end of prostate cancer, and so I'm heavily involved with them, I have a great relationship, and so we were looking for ways to really spark interest in prostate cancer awareness. There's the annual prostate cancer run walk, but we weren't having such great attendance. Certain normal patients would show up regularly, but we weren't having much growth. We were trying to find different ways to really make a fun way to raise awareness. And so we came up with this Pies For Prostate campaign awareness, and it actually, it went pretty well. We did a spot on. If we could raise a certain amount of money in a certain amount of time, a flash raised, then I would get a pie to the face. And so they're on stage, and I think we've got YouTube footage of this. It's quite funny. Our practice administrator, after all the torture I put her through being my administrator, she gladly slammed a pie into my face as we met our raise and met our goal.

0:04:32.0 DS: She was very satisfied. [chuckle]

0:04:33.4 DG: Yeh, yeah. But that was in 2019, and so 2020 COVID hit, and so all these events were cancelled, but as you know, there's still patients with prostate cancer, there's awareness that needs to be done. Just because of a pandemic doesn't mean that all these efforts stop. So we created a virtual Pies For Prostate campaign, and we were able to raise almost $25,000 during a pandemic for prostate cancer awareness through this campaign. So something I'm definitely very proud of, and will continue to promote.

0:05:09.7 DS: Who's hitting you in the face virtually? How does that work? [chuckle]

0:05:16.2 DG: Well, so, I decided to Pie It Forward, and I lovingly volunteered people that as we met certain goals at $5000, $10,000, $15,000, that certain people would get pied rather than myself. I learned my lesson from the first year.

0:05:32.9 DS: [chuckle] Well, that's great. No, thanks for all you're doing for patients. You have a different perspective, I think, coming into urology, you're a younger urologist. How do you really see how the field is changing from your vantage point? 

0:05:51.8 DG: Yeah, I think I'm living through it right now. I think we're seeing a lot of these changes where, at conferences, it's a very big topic amongst a lot of practices that there is a considerable amount of retiring urologist and there are not enough graduating urologist to help fill that need. And as urologists are getting older, more than half of the practicing urologists are already over the age of 55. That in our practice, our average age is about 46, we really steer on the younger side, but I think there's significant value that comes with that. There's a lot of fresh ideas, there's a lot of new things that become incorporated that a lot of medicine unfortunately becomes muscle memory, becomes habit that I was trained to do this, even if it was 30 years ago. And continuing medical education does help to try and keep everyone fresh and updated, but some habits are hard to break. I think having these young blood coming in really forces you to think that, can we be doing it a different way? Can we be doing it better? The growing forces for advanced practice providers are strong, so you're seeing a lot of physician assistants, a lot of nurse practitioners coming into urology. And there's a lot of support for this, because the growing urologic needs are high, and so to meet that demand, you need a workforce.

0:07:27.3 DS: What are some of the... Any examples there that you see between some of the younger urologist and the older practicing urologist in clinic? 

0:07:36.5 DG: Yeah, I can tell you, technology is a big thing, just rolling out with... I think we all noticed this during the pandemic, but QR codes became very popular, and they've been around for a while, but just people never really adopted it. Now it's somewhat standard, but...

0:07:54.5 DS: Can't even go to a restaurant now without a QR code.

0:07:57.0 DG: Absolutely, no one wants to give you a physical menu. We've seen just the adoption of technology and our practice grow tremendously with, TeleVisits during the pandemic, and then shifting now towards patient education, YouTube channels, all these things that really allow for the way the younger generation accesses information more than the traditional going to a doctor's office, having a conversation. I think Google has really changed so much of that patient-physician relationship.

0:08:34.7 DS: Yeah, it has greatly changed across the board, if you think of... Even you brought up continuing medical education, if you see what's happening, even with meetings now, where a lot of meetings are getting hybrid components to it, but people are largely, I think, on the clinical side, getting a lot of information as you mentioned from the web, from... Information is just so bountiful now from all over.

0:09:01.2 DG: Yeah, and I think it's good and bad. I think from a patient standpoint, they may have trouble determining what's a valid source versus what's just a random person's blog. I think from the clinicians standpoint, we have certain vetted out websites, web check, or a lot of people have up-to-date subscriptions through their EMRs, things that we can use to assess different new clinical guidelines rather than just a simple Google search, but I think the use of technology is rampant. I think in a younger generation, I think we're starting to see that evolve with some of our younger doctors, and they come with a different perspective as well. I still consider myself one of the younger doctors, but...

0:09:52.0 DS: You're young until you're old. [chuckle]

0:09:55.4 DG: Exactly, I like that. And it's just, we see that they have a lot of different ideas that I feel when I joined our practice, I would come with fresh set of eyes of things we could try, and every doctor that gets hired has that same opportunity. And so we owe it to them to listen to these ideas as we try to improve our patient care, our patient access, and our patient education.

0:10:22.9 DS: Yeah, well said. How do you see patients using social media in practice? 

0:10:28.9 DG: Most of it right now is with TeleVisits, doing video visits. I think that technology has really allowed that with iPhones or Androids, allowing for video chats. This has become just something that's just normal that people do with their family members. Most of my TeleVisits are funny because you'll have patients at work, you'll have patients on a beach, very rarely do you have patients sitting at a desk dedicated to this visit. But it just becomes part of their normal day. I think social media for us, patient education platform, something that we can post what to expect before a surgery, what to expect after a surgery, something that is repetitive, we tell the same speech to certain patients, this really allows patients to view the video of what to expect so they know before the procedure or after the procedure, what's normal, what's not normal, when to call, rather than constantly calling with different questions. I think that's where the biggest utility for us has been, is with patient education.

0:11:39.7 DS: Yeah, and a few pies to the face, it sounds.

0:11:43.0 DG: Right. [chuckle]

0:11:46.4 DS: I know when it comes to genetic testing in particular, a lot of people out there are... When it comes to the patient side, it comes up on searches, and they bring that information into practices. How are you seeing the role of genetic testing and prostate cancer detection and treatment evolving? 

0:12:05.7 DG: Yeah, I think prostate cancer is at a great stepping stone right now, and it's actually quite exciting to be involved in it. We've seen what's happened with breast cancer, and prostate cancer unfortunately has lagged by about 50 years. But you've seen changes with breast cancer from doing total mastectomies to doing focal therapies, to doing genetic screening and preventative measures. And I think we're starting to now see that with prostate cancer, we're starting to learn a lot more that it is quite similar to breast cancer. We are learning that maybe doing a radical prostatectomy or a whole gland radiation therapy may not be needed for certain patients, and I think there's a lot of research going into this about the utility of focal therapy for treatment for prostate cancer, and I think we're entering that era of personalized medicine and patients that are becoming more aware of that, you're seeing more commercials about it.

0:13:07.4 DG: But with the widespread availability of both genomic testing and genetic testing, we're now able to finally get down to the nitty-gritty of a patient-specific tumor. Usually we give statistics related to a patient's prostate cancer, that if you have a Gleason 4 + 4 = 8, this is your chance for metastatic disease, this is your chance for cancer-specific survival. But those are statistics that the way I describe to a patient that out of 100 patients, not every patient is gonna follow that line, and patients ultimately don't care about the other 99 patients, they wanna know about themselves and what does my Gleason 8 cancer mean. And so I think they're more aware and attuned to personalize medicine, and I think that's where you're seeing a lot of this utilization of the Internet, social media to really search that. Because I think unfortunately from a clinician standpoint, we're still figuring a lot of this out from a research standpoint, but there's a lot of barriers to implementing that within clinical practice as well.

0:14:23.1 DS: Yeah, and are you using these tests in your practice in partnership with the patient to help guide their care? So say for instance, the Gleason 8 patient, are you using genomic tests on top of that to modify your recommendations or have shared decision-making? 

0:14:41.5 DG: Yeah, so I think from initial diagnosis, we do try to incorporate genomics right off the bat at the time of biopsy to help with those decisions, that we do discuss with the patients that what that test tells us is not gonna determine your treatment, but it's another data point, just like PSA, just like an MRI, just like a Gleason score, these are all data points that we have to take together to create the whole picture.

0:15:09.8 DS: Yeah, gene expression profiling on the tumor, I guess, just for the audiences is what we're honing in on, I guess, I should say.

0:15:20.8 DG: Yeah, but it's become so more prevalent, and our conversations with patients are a lot more pointed because now we can give specific risk about metastasis and mortality at five years, 10 years, 15 years to that patient.

0:15:37.3 DS: Yeah, yeah. And what about the tumor as metastatic or advanced, are you using genomics in that context too to think about therapy selection or work with the medical oncology colleagues? 

0:15:49.8 DG: Yeah, so a lot of times in those instances has been where we've tried to really utilize the genetic testing to really identify if they have any true mutational changes that would have some benefit with the newer treatments that have emerged with some of these PARP inhibitors. I think one of the things that help to change our education for this was the ability to dispense these medications through our pharmacy, and so creating an in-office dispensary has allowed us to be more educated about these certain medications as well as how to identify the patients, therefore, how to incorporate genetic testing into our practice. And I think it's very different 'cause you're looking at the end game of this medication, and what do you have to do to find a patient who's eligible for this medication, that I think has allowed us to really enter into this genetic testing and understand who's a candidate and who we really should be testing to find out the patients that would benefit the most.

0:17:02.9 DS: And there you're talking about, just to be clear, blood-based genetic testing? 

0:17:08.2 DG: Correct, and especially in the metastatic patients.

0:17:12.6 DS: Someone's generic line, yeah, of their mom and dad genetics. Yes, that's [0:17:15.1] ____ understandable.

0:17:15.0 DG: Absolutely.

0:17:15.1 DS: And what about, do you ever use then tumor testing too? Sometimes you can grind up the tumor, look for mutations and things like that, that would go... A lot of times it can include obviously things like PARP inhibitors, but often it starts getting into precision diagnostics.

0:17:31.5 DG: Yeah, I think we're heading in that direction, and so I think there's a lot of lack of education in terms of on the clinician standpoint of who truly could benefit from those tests, as well as the financial impact. I think there's a lot of concern regarding, "Will this be covered by insurance? Will my patients get a bill?" And a lot of that uncertainty leads to, "Maybe I shouldn't order it because I don't really have an answer for my patient." And so we've somewhat dedicated some resources towards working with patients on that so that we can make sure that will it be covered for them. But I think one thing I've learned is having that upfront conversation, even if I don't know if it's covered or not, if I feel it's something that can benefit them from a cancer standpoint, most patients will elect to move forward with it. And I think as we started this discussion about being the patient's best advocate, I firmly believe in that, and a lot of that means that I need to also offer them all of their options regardless of cost, but letting them know that this is also a possibility to get more data.

0:18:49.5 DS: Yeah, that's what I was gonna ask. What kind of barriers? It sounds like cost is a big one, and this is a cutting edge, this is the Modern Urologist. The implementation of genetics and genomics, both on the tumor side, the mom and dad genetic side to help guide therapy, that is really emerging right now. And guidelines are changing yearly and incorporating more and more and different indications. And insurance companies are trying to figure out how they're gonna pay for these and what they wanna pay for and which indication, so it is really in flux, so that's an important point.

0:19:30.6 DG: Yeah, and I think a lot of this is, we do try to stay cutting edge, as you're saying. That's one of our goals with our practice, to be able to offer patients the latest that's available. Unfortunately, insurances do lag behind in that, and then that can sometimes come at a detriment. We may sometimes have upset patients who end up with a large bill and they say, No one told me I would be getting this large bill. There are some bumps in the road as we go through this process. But at the end of the day, I do believe it is something that is more beneficial for patients to have that information that not only can impact them, but can impact their loved ones.

0:20:13.9 DS: Yeah. No, well said. Do you see any other barriers in practice to implementation? You had spoken a little bit about education. Anything else that you see? 

0:20:22.2 DG: When you talk about the barriers, it's very tough when you have 10 docs in your practice and everyone's trying to do this and dabble in it. It's hard to understand all the nuances associated with it, but if you have two or three champions that this is what they do day in and day out, it's really... You become an expert in that area. You become someone who's like, "Oh yeah, I know how to navigate the insurance aspect, I know what's approved. I know that." That's something we're trying with our practice now, we've got a couple of champions dedicated towards advanced, a couple of champions dedicated towards localized. And so those champions are trained like who are candidates, and so we can start incorporating this in more.

0:21:06.1 DS: That's great.

0:21:08.2 DG: Now we have some advanced prostate cancer champions, my partner Dr. Desai and our nurse practitioner Anteneh, they're prostate cancer champion, so alongside me, I oversee the program, and then they're helping to implement it. That's why this is one of the next phases we're trying to bring in this year.

0:21:28.1 DS: No, that's really nice. Well, thank you so much for coming on, Dr. Gandhi. This was very informative for me. I loved hearing your perspective on how it is emerging as a younger urologist in clinic and trying to think about all the advancements in the field at the same time of trying to take care of your patients and reduce financial toxicity, thinking about the barriers that they're facing. And we covered a lot of ground, even the social media and the aspects of web and how patients and clinicians are really using this information to try to educate themselves and do the best to improve prostate cancer care. So I just wanna say thank you so much for coming on the podcast today. I hope our listeners learn something. I know I did.

0:22:23.1 DG: Yeah, no, thank you for having me. And hopefully we'll get you to sign up for a Pie For Prostate campaign here soon. I think by bringing it up, you've now signed yourself up, so get ready.

0:22:36.7 DS: [chuckle] That's fine, maybe I'll take a pie to the face. [chuckle] Well, thank you again.

0:22:42.3 DG: Awesome, thank you. Thank you for having me.

0:22:48.4 This podcast is brought to you by Myriad Genetics. If you'd like to learn more about our genetic testing solutions to personalize prostate cancer treatment, visit myriad.com. If you like what you're hearing, make sure to share, subscribe, or leave us a review. Until next time.